American Journal of Gastroenterology最新文献

Background: A treat-to-target strategy for inflammatory bowel disease (IBD) recommends iterative treatment adjustments to achieve clinical and endoscopic remission. In asymptomatic patients with ongoing endoscopic activity, the risk/benefit balance of this approach is unclear, particularly with prior exposure to advanced therapies.

Methods: Using the RAND/University of California Los Angeles Appropriateness Method, 9 IBD specialists rated appropriateness of changing therapy in 126 scenarios of asymptomatic patients with ulcerative colitis and Crohn's disease and active endoscopic disease. Disease extent and behavior, prior treatment, prior complications, and recent disease progression were considered, as were factors that might influence decision-making, including age and pregnancy. Ratings were collected through anonymous survey, discussed at an in-person meeting, and finalized in a second anonymous survey.

Results: Panelists rated change in therapy as appropriate (i.e., expected benefit sufficiently outweighs potential harms from continuing therapy) in 96/126 scenarios, generally in patients with progressive, complicated, and/or extensive disease, while changing therapy was rated uncertain in 27 scenarios of mild and/or stable disease. Changing therapy was rated inappropriate in ulcerative colitis patients with mild and stable disease previously exposed to ≥3 therapies or with improved endoscopic activity, and in Crohn's disease patients with only scattered aphthous ulcers. The validated threshold for disagreement was not crossed for any scenario. Patient age older than 65 years and a plan for pregnancy in the next year might influence decision-making in some settings.

Discussion: Appropriateness ratings can help guide clinical decision-making about changing therapy to achieve endoscopic remission in asymptomatic patients with IBD until data from ongoing randomized studies are available.

Introduction: Primary sclerosing cholangitis (PSC) may reoccur following liver transplantation (LT), and the diagnosis established once imaging studies demonstrate the diagnostic cholangiographic appearance. To evaluate whether the development of recurrent PSC (rPSC) is associated with cholestasis soon after LT, we studied whether changes in hepatic biochemistry within the first 12 months were linked with the development of rPSC and graft loss.

Methods: We conducted a retrospective cohort analysis of 158 transplant recipients with PSC in Canada and 549 PSC transplant recipients from the United Kingdom. We evaluated serum liver tests within 12 months after LT and the subsequent development of a cholangiographic diagnosis of rPSC as a time-dependent covariate using Cox regression. Severe cholestasis was defined as either alkaline phosphatase > 3× upper limit of normal or total bilirubin > 100 μmol/L.

Results: Patients who developed rPSC were more likely to have severe cholestasis vs those without at 3 months (20.5% vs 8.2%, P = 0.011), at 6 months (17.9% vs 10.0%, P = 0.026), and 12 months (15.4% vs 7.8%, P = 0.051) in the Canadian cohort and at 12 months in the UK cohort (27.9% vs 12.6%, P < 0.0001). By multivariable analysis, development of severe cholestasis in the Canadian cohort at 3 months (hazard ratio [HR] = 2.41, P = 0.046) and in the UK cohort at 12 months (HR = 3.141, P < 0.0001) was both associated with rPSC. Severe cholestasis at 3 months in the Canadian cohort was predictive of graft loss (HR = 3.88, P = 0.0001).

Discussion: The development of cholestasis within 3-12 months following LT was predictive of rPSC and graft loss.

Introduction: Despite a growing armamentarium of medical therapies for ulcerative colitis, colectomy remains an important therapeutic option. To better inform shared decision-making about surgery, we estimated the contemporary risk of mortality after colectomy.

Methods: Mortality rates were estimated using the National Inpatient Sample (2016-2020). Factors associated with postcolectomy death were evaluated in multivariable regression.

Results: Postcolectomy mortality occurred in 1.2% (95% CI: 0.8%, 1.9%) of hospitalizations. Comorbidity burden, emergent laparotomy, and delays to surgery >5 days after admission were associated with mortality.

Discussion: Colectomy may be associated with mortality; however, this risk is heterogeneous based on patient- and procedural-related factors.

Introduction: This study investigated the detection rate of colorectal neuroendocrine neoplasms (NENs) using large-scale colonoscopy data.

Methods: This cross-sectional analysis used large-scale data from a Japanese multicenter observational study of colonoscopies performed from 2010 to 2020.

Results: Among 82,005 colonoscopy cases, colorectal NENs were identified in 71 (67 of which were neuroendocrine tumors), with a detection rate of 0.087% (95% confidence interval: 0.069-0.109). Most were small rectal lesions, with only 4 >10 mm in size and 3 located in the colon.

Discussion: The detection rate of colorectal NENs during colonoscopy is substantially higher than expected.

Article Title: Diagnosis and Management of Clostridioides difficile in Inflammatory Bowel Disease.